Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States (U.S.). and poverty is a risk factor for increased COPD prevalence and morbidity. While cigarette smoking is one reason that COPD is increased among the poor, there are other exposures that likely contribute to health disparities and put poor individuals at increased risk, including air pollution, obesity, and adverse dietary patterns. While great efforts to determine the burden of COPD worldwide have identified indoor biomass as a causative environmental exposure and international efforts to develop targeted interventions to reduce COPD prevalence and morbidity are ongoing, there has been relatively little attention to the problem of COPD in poor, rural regions in the U.S. South Central Appalachia represents one of the most disadvantaged regions in the U.S. Most of Appalachia is rural and characterized by low income, limited education and geographic isolation, factors associated with poor health. While relatively few studies have directly assessed indoor air quality in this region, preliminary work by our group suggests that indoor burning of fuels is prevalent and that homes have elevated indoor nitrogen dioxide (NO2) and particulate matter (PM), even exceeding concentrations typical of urban settings. Living in Appalachia also increases the risk for obesity and adverse dietary patterns, factors that may enhance susceptibility to pollutant effects. The South has the highest prevalence of obesity and, analogous to urban food deserts, rural Appalachia has food deserts that enhance the likelihood of adverse dietary patterns. Our own work in Baltimore City has added to the emerging literature that body mass may contribute to susceptibility to air pollution, yet the role of adverse dietary patterns may play a role in this enhanced susceptibility to air pollution remains unknown. A critical next step in designing interventions to reduce heath disparities and improve the respiratory health of high-risk rural populations is to identify the sources of indoor air pollution in this region and determine the risk for respiratory health effects among susceptible individuals with COPD. Project 2 builds capacity and brings together a multidisciplinary team of investigators from Johns Hopkins and East Tennessee State University to understand environmentally driven health disparities in a rural, low-income population. We will conduct a longitudinal cohort study of 100 former smokers with COPD, including one week of home environmental monitoring and simultaneous health outcomes assessment at baseline, 3 and 6 months, with the following aims. 1) To measure and determine sources of household air pollution among former smokers with COPD in Appalachia. 2) To estimate the effect of indoor air pollution exposure on respiratory morbidity among former smokers with COPD in Appalachia. 3) To explore independent effects of body mass and dietary intake on susceptibility to respiratory health. Project 2 complements Project 1 and contributes to CURE COPD Program's overall goal of reducing health disparities by defining the contribution of air pollution, obesity, and adverse diet (risk factors that are increased among the poor) to COPD morbidity in rural Appalachia.